The Highs And Lows Of Opiate Management
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The Highs And Lows Of Opiate Management

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Guidelines for the management of opiate prescribing by physicians.

Guidelines for the management of opiate prescribing by physicians.

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The Highs And Lows Of Opiate Management The Highs And Lows Of Opiate Management Presentation Transcript

  • THE HIGHS AND LOWS OF OPIATES
    A REVIEW OF THE CPSO GUIDELINES
    Leon Rivlin MD, CCFP (EM)
  • OBJECTIVES
    Evaluate opioids in the management of chronic pain
    Define an approach to the recognition of opioid misuse in the chronic pain patient
    Evaluate protocols for safe and effective prescribing of opioids in chronic pain
    Discuss the pitfalls of opiate management
  • WHY IS OPIATE MANAGEMENT SUCH A GREAT CONCERN ?
    WHY IS CHRONIC PAIN IMPORTANT?
  • Canadian National Pain Study 2002
    Chronic pain is present in 22 – 39% adults
    #1 reason for chronic pain: arthritic conditions
    Prevalence of pain increases with aging
    Only 36% of patients felt that their pain was effectively Rx
    68% of MD’s believed that chronic pain could be treated more effectively
    Moulin D., PR&M, 2002,2003
  • ECONOMIC IMPACT
    13% of workers lose a mean of 4.6 hours /wk of productive work time due to common pain conditions
    Costs to industry $6.2 B/yr (US) 76 % due to reduced performance at work
    Costs of depression to industry $31 B/yr
    Equal to impact of CV disease, or Cancer
    Stewart et al. JAMA 2003
  • BARRIERS for PHYSICIANSto TREATING CHRONIC PAIN
    Limited training in medical schools
    Insufficient knowledge and understanding
    Disease centred model of care does not prioritize the management of pain
    Biopsychosocial model of pain underutilized
    Fears about regulatory bodies
    Biases and fears about opioid use & addiction
  • BIASIS & FEARS ABOUT OPIOID ANALGESICS 2004 DATA
    Study of Wisconsin physicians' knowledge and attitudes about opioid analgesic regulations
    David E. Weissman, MD; David E. Joranson, MSSW; and Margaret B. Hopwood, MA, RN, Milwaukee and Madison Wisconsin Medical Journal 1991
    200 Wisconsin physicians were polled
    54% of the respondents indicated that, due to concern of regulatory scrutiny, they will do one of the following: reduce drug dose or quantity, reduce the number of refills, or choose a drug in a lower schedule
  • EFFICACY OF OPIOID USE IN THE MANAGEMENT OF CHRONIC PAIN
    Some but not all trials show functional improvement (Arkinstall et al., Pain 1995)
    Subjective pain ratings show a 20 – 50 % decrease with a wide variation of individual response (Watson & Babul, Neurology 1998, Moulin et al, Lancet 1996)
    • Opioids are better than NSAIDS or TCA’s for pain relief but not for improved functional outcomes (Sandoval, Furlan, Fonseca, Tunks, Mailis, submitted for pub)
    Quality of life may improve with optimal dosing
  • ADVERSE EFFECTS of OPIOIDS:GENERAL
    Constipation, nausea, narcotic bowel syndrome
    Sweating
    Sleep apnea, COPD, reduced resp. drive
    Rebound head aches
    Fatigue, confusion
    Cognitive impairment
    Endocrine & Reproductive effects (suppression of testosterone, menstrual irregularities)
    Lowered pain threshold (long term hyperalgesia due to altered pain receptors)
    Neurotoxicity (Demerol)
  • ADVERSE EFFECTS: OVERDOSE
    Decreased LOC
    RR < 12/min
    Bradycardia
    Speech slow & drawling
    “Nodding off” appear to fall asleep momentarily during conversation
    Patients may appear to be relatively alert when surrounded by others in a stimulating environment, only to drift into coma and die when going for a nap
    Pinpoint pupils
    Ataxia and falling
    Emotional lability
    Disinhibition
    Profuse sweating
  • ADDICTION
  • ADDICTION
    Addiction occurs when a patient finds a drug effect so reinforcing that he has difficulty controlling its use
    Characterized by the four C’s:
    Loss off over use Control
    Use despite knowledge of harmful Consequences
    Compulsion to use the drug
    Craving
  • ADDICTION & OPIOIDS
    50% chronic pain patients are addicted to opioids
    More formal studies found addiction rates to be 3 – 19%
    54% of injection users inject morphine and hydromorphone, 42% inject heroin
    7-31% prevalence for opioid misuse behaviors (running out, double doctoring)
  • CLINICAL FEATURES of ADDICTION
    Use of higher doses than needed for pain control
    Run out early
    Reluctant to try alternatives to drug of choice
    Acquire opioids from friends or other doctors
    Tendency to binge on opioids
    Deterioration in functional status
    Daily cycle of intoxication and withdrawal
    Experimenting with opioids (routes of administration)
  • OPIOID OVERDOSE:RISK FACTORS
    Dose, potency, underlying tolerance
    Age (extremes), renal insufficiency, respiratory disease
    Restarting opioids
    When a patient has been off of an opioid for 3 days or longer, restarting at the same dose may produce an overdose due to rapid decline in tolerance.
    Restarting the medication should be at 50% of the previous dose with gradual titration up.
  • OVERDOSING
    17% opioid users had an overdose in past 6 months
    Risk for overdosing:
    • injecting
    • high potency opioid use
    • concurrent use of prescription opioids & benzos
    • tolerance
    • depression
    • participation in abstinence based programs
  • GUIDELINES TO OPIOID PRESCRIBING
  • PREPARE A TREATMENT PLAN
    Collect information and formulate a diagnosis
    Define and priorize treatment targets
    Devise a COMPREHENSIVE treatment plan
    Lifestyle changes
    Social changes
    Consider Psychological/Psychiatric intervention
    Integrate paramedical care providers
    Pharmacotherapy
    Interventional medical therapy
  • START WITH NON-OPIOIDS
    Opioids should only be initiated after an adequate trial of non-opioid analgesics and other modalities have failed
    Treatment success is measured by 25 – 50 % diminished pain, improved mood, and improved function
    Abstinence of pain is an unrealistic goal
    General reluctance to use opioids for headaches (opioids 2nd/3rd line at best)
  • INITIATING OPIOIDS
    Obtain informed consent (adverse effects, risk of dependence)
    Set expectations (25 – 50 % relief of pain)
    Identify one prescribing physician
    Sign a Treatment Agreement
    Evidence supports improved compliance
    Sandoval et al., 2005
  • Maximum Opiate Dose is 200 mg morphine /dayCPSO TASK FORCE CONCLUSIONS
  • COMPONENTS OF THE TREATMENT AGREEMENT
    Patient will not receive opiates from other sources
    Detail the amount of medication, and usage schedule
    Will not refill if the patient runs out early
    Will not replace if meds or script lost
    Patient will attend to regular visits
    Urine drug screen will be provided on request
    Physician can cease opiate script if agreement broken
    A copy of the agreement should be sent to other physicians involved in care
    Consequences of breaking the agreement should be specified and adhered to
  • DOCUMENTATION
    Keep an opiate flow sheet (record the amount dispensed and reasons for changes)
    Keep copies of scripts on chart
    Orange paper scripts are hard to photocopy
    See patient frequently on initiation of treatment
    At each visit, document: compliance, adverse effects, changes in mood and functional status, and analgesic effectiveness (VAS)
  • OPIATE SELECTION, DOSAGE & TITRATION
    There is no evidence that one opiate is superior to another, recommendations are based on specific patient populations
    Codeine is usually the initial choice because it is the least potent
    Be cautious of the acetaminophen component
    4 g/d if healthy, 3.2 g/d if elderly, 2g/d if EtOH
  • OPIOID SELECTION
    10% of Caucasians can’t convert codeine
    Fentanyl patch, oxicodone, & hydromorphone are less likely to cause sedation in elderly
    Active metabolites of morphine can accumulate in renal dysfunction
    Avoid oxycodone & hydromorphone in patients with addiction history
    Methadone is first choice in chronic pain among addicts
    Parenteralopioids should not be use in long-term pain due to risk of overdose, addiction, and other problems
  • Titration
    Start low and go slow!
    Opiates have a graded analgesic response with greatest benefit at lower doses and plateau at higher dosages
    Confirm that with each dosage increase there is a decline in the VAS pain score
    Avoid withdrawal especially in pregnancy
    Titrate slowly in the elderly, co-sedating med users, renal, resp, hepatic disease
  • BREAKTHROUGH PAIN
    Opioids should be taken on a regular basis
    Should be 1/3 of total scheduled dose or less
    Same opiate should be used for scheduled and breakthrough use
    No convincing evidence for combining different types of opioids
  • SWITCHING OPIOIDS
    Switch if lack of effectiveness or intolerable side effects
    Initial dose of new opioid should be 50% of the original opioid used
    Discontinue if pain remains unresponsive after 3 or 4 different opioids
  • SAFE PRESCRIBING
    Avoid prescriptions for large amounts
    Caution with high dependence opiates in those at risk
    Use rescue doses sparingly
    Should be time dependent rather than pain contingent
    Max of 4 – 6 doses per month
    Reduce next days dose by equal amount
    Tamper proof the prescription
    Keep track of the medications
    Running out early is common in addiction
  • TAMPER PROOFING PRESCRIPTIONS
    • Use words and numbers
    • Use lines in blank spaces
    • No repeats
    • Keep pad in safe place
    • Numbered, non reproducible pads (orange is hard to photocopy)
    • Do not allow phone repeats
  • FEATURES OF OPIOID MISUSEPatients are reluctant to acknowledge their addiction for fear their opioid will be discontinued and they will experience withdrawal & pain
    Past history of recreational drug & EtOH use
    Patient or family have concerns about use
    Patterns of use (binge, running out early)
    Overstating effectiveness, dramatic and unlikely analgesic effect of pain
    Psychological dependence; mood levelling effect, relief of anxiety, sense of calm
    Withdrawal symptoms
    Withdrawal mediated pain
    Psychiatric history
    Psychosocial Status (family conflict, deterioration at work)
    Double doctoring
    Physical findings
    Lab findings (CBC, AST,ALT, HepB,C, GGT, MCV)
  • IN SUMMARY
    Formulate a comprehensive treatment plan
    Include the patient & family in the decision making
    Consider opioids late in treatment of pain & use sparingly
    Monitor use of opioids closely
    Dispense small quantities of medication on any one visit
    Frequently evaluate effectiveness of treatment models & guidelines
  • THE END